Otomycosis With Tympanic Membrane Perforation: A Review of the Literature

Petros Koltsidopoulos MD, PhD, Charalampos Skoulakis, MD, PhD

First Published May 29, 2019 Review Article 

https://doi.org/10.1177/0145561319851499

Article information

 

Abstract

Objective:

The purpose of the present study was to assess the rate of tympanic membrane perforation in patients with otomycosis and to discuss the literature regarding the difficulties in managing this condition.

Data Sources:

Literature review from 1999 to 2019, Web of Science, PubMed, and Medline.

Study Selection:

We searched for eligible articles concerning the clinical entity of tympanic membrane perforation secondary to otomycosis. Case series and clinical trials were the types of articles included for this review.

Data Extraction:

All the articles described in the study selection were used for this review.

Data Synthesis:

Statistical techniques were not used.

Conclusion:

Based on the available literature, it seems that tympanic membrane perforation secondary to otomycosis is not uncommon. The presence of this complication is associated with 2 problems: Antimycotic solutions are irritant to middle ear and may be ototoxic to the cochlea. Although most cases of fungus caused tympanic membrane (TM) perforation resolve with proper medical treatment, in a few patients a tympanoplasty may be required.

Keywords otomycosis, fungal otitis externa, tympanic membrane perforation, tympanoplasty

Introduction

Otomycosis is a superficial fungal infection of the external ear canal that is frequently seen in primary care and otolaryngology practices. It is a worldwide disease, but is more prevalent in the warm, humid climate.¹There has been an increase in the prevalence of otomycosis in recent years due to the extensive use of antibiotic eardrops.^2,3 Other predisposing factors for the development of otomycosis are frequent swimming, an immunocompromised host (eg, diabetic mellitus, acquired immune deficiency syndrome), pregnancy, postcanal wall down mastoidectomy, tympanic membrane perforation, hearing aid wearing, and self-inflicted injuries (eg, by cotton swabs).⁴ Diagnosis is mostly clinical, and Aspergillus and Candida species are the most commonly identified fungal pathogens.⁵ Fungal pathogens have been reported to cause 9% of all cases of otitis externa, but this figure appears to be on the rise, presumably because of the increased use of topical antibiotics.⁶ Treatment recommendations include local debridement along with antifungal medication, either local or systemic.⁷ An infrequently reported complication of otomycosis is tympanic membrane perforation.⁸ In a clinical study by Ram Kumar, the incidence of tympanic membrane perforation in otomycosis was found to be 11%, and perforation was more common with otomycosis caused by Candida albicans.⁹

The objective of the present review was to assess the rate of tympanic membrane perforation in patients with otomycosis and to discuss the literature regarding the difficulties in therapy associated with this pathology.

Materials and Methods

We searched PubMed and MEDLINE databases from 1999 to 2019 for original articles and case series concerning the clinical entity of tympanic membrane perforation secondary to otomycosis. Only articles published in English were reviewed.

The following search terms were used: otomycosis, fungal otitis externa, tympanic membrane perforation, tympanoplasty, and myringoplasty. Limiting search terms were case series and clinical trial. Additional articles were identified by hand-searching the reference lists of the retrieved articles. Cases reports describing patients with tympanic perforation caused by otomycosis were excluded. Two authors (P.K. and E.P.) independently graded the articles for eligibility criteria, and any disagreement was resolved by discussion. Analysis of the literature did not permit a systematic review to be performed because the studies included were heterogeneous and were not designed to answer our main question.

The found articles were analyzed with regard to the rate of tympanic membrane perforation in patients with otomycosis. The search focused also on the difficulties regarding the conservative treatment of otomycosis related to this complication. Finally, the included studies were analyzed regarding the incidence of persistent TM perforation after failure of conservative treatment.

Results

We included 10 articles concerning the clinical entity of tympanic membrane perforation secondary to otomycosis. The initial search using the terms “otomycosis” and “tympanic membrane perforation” yielded 19 citations of which 6 failed to meet the inclusion criteria and 3 were not published in the English language. Moreover, 2 articles were excluded because they were case reports. Finally, 3 articles were excluded because they reported treatment of otomycosis with a previously perforated TM. The remaining 5 studies were included in the review. The use of the rest search terms and the hand-search yielded 5 additional studies, bringing the number of articles meeting the inclusion criteria to 10 (Figure 1). The articles were either case series or clinical trials.^{6–8,10–16}

Figure 1. Flowchart of the reviewing process.

Rate of Tympanic Membrane Perforation

Table 1 summarizes the incidence of TM perforation of each study. In total, there were 928 patients included. Rates of TM perforation rates in patients with otomycosis varied from 0% to 16.67%.^11,14

Table 1. Summary of Articles on Tympanic Membrane Perforation Secondary to Otomycosis.

Table 1. Summary of Articles on Tympanic Membrane Perforation Secondary to Otomycosis.

View larger version

It is clear that studies in the literature use similar criteria in order to define that a TM perforation is etiologically associated with the fungal infection and is not a preexisting condition. Namely, all authors agree that TM perforations should be considered as a complication of otomycosis fungal infection if they are present during the initial presentation and healed with the resolution of infection or if they are observed to occur during the course of treatment. Moreover, in many studies, the absence of ear problems was considered as a clue that the complication is due to the otomycosis. Two authors did not mention the criteria on which the causal relationship between TM perforation and otomycosis was based.^13,15

Rate of Persistent TM Perforation

In most of the studies, there was no report on the percentage of TM perforations secondary to otomycosis that resolved with conservative therapy. Only 3 studies evaluated the efficacy of conservative therapeutic approach.^6,8,16 All of them demonstrated that most perforations tend to heal when the ear becomes free of fungal external otitis. Table 1 summarizes the results of each study. In total, there were 51 patients included. The range of persistent TM perforation rates in patients with otomycosis varied from 5.5% to 27%.^6,16 Most of the cases of persistent TM perforation required a tympanoplasty. Hurst performed cauterization with trichloracetic acid in a patient with a tiny perforation.⁸ In the study of Song et al, a patient required a fat-graft myringoplasty.¹⁶

Discussion

Tympanic membrane perforation may occur as a complication of otomycosis. It is an infrequently reported clinical feature of fungal otitis externa that general practitioners or even otolaryngologists are not always aware of. At the same time, it is one of the most misleading manifestations of otomycosis and can lead to incorrect diagnoses.⁸ TM involvement is likely a consequence of fungal inoculation in the most medial aspects of the external canal or direct extension of disease from adjacent skin. The pathophysiology of this complication has been attributed to avascular necrosis of the TM as a result of mycotic thrombosis in the adjacent blood vessels.⁸ Most of the perforations were behind the handle of the malleus. There are no clinical features predictive of TM perforation.

Rate of Tympanic Membrane Perforation

Although the association of TM perforation with otomycosis has been a known clinical problem for many decades, its incidence has never been precisely quantified. Data derived from epidemiological studies carried out to evaluate the incidence, clinical aspects, and outcomes of otomycosis are conflicting in this regard. The range of TM perforation rates in patients with otomycosis is quite wide.^11,14 This may be related to the fact that the diagnosis of TM perforation secondary to fungal otitis externa is based on clinical examination and can be difficult. First, complete removal of the fungal and epithelial debris using a microscope is required so that the entire TM can be visualized. Moreover, the size of perforation is usually quite small, making its detection difficult. Due to the abovementioned factors, it could be assumed that many cases are misdiagnosed. Additionally, some authors, especially in older studies, used to attribute the presence of TM perforation to chronic otitis media, without taking into consideration that the defect could be associated etiologically with the fungal infection of the ear.^17,18 Various factors such as the criteria used for otomycosis diagnosis and recording practices can significantly influence the reported incidence of otomycosis TM perforation. Viswanatha et al found that TM perforation is more in immunocompromised patients than in immunocompetent patients.^19,20 Another possible reason for the wide range of TM perforation incidence may be the small sample size in some of the studies.

However, it should be underlined that there is a number of clinical studies that reported similar rates of TM perforation.^6,7,12–14 According to them the incidence of TM perforation secondary to otomycosis is over 10%. Thus, it cannot be considered as an uncommon complication.

Difficulties With Regard to Conservative Treatment

The most widely used treatment regimen for otomycosis includes mechanical debridement of the ear canal along with local antifungal agents. However, the presence of TM perforation is associated with 2 problems: antimycotic solutions are irritant to middle ear and may be ototoxic to the cochlea.

Namely, direct instillation of antifungal agents with a dropper is associated with stinging and burning sensation.²¹ Clotrimazole, which is the most commonly used antimycotic medication, is practically insoluble in water. Solvents used in dermatologic solution are propylene glycol, isopropyl alcohol, and polyethylene glycol. Although they have a good drying effect, they are irritant to middle ear mucosa and cause burning or stinging sensation. In order to prevent this unpleasant condition, many authors have proposed alternative topical therapeutic options. Insertion of an ear wick saturated with antifungal solution or cream may be used to increase the contact time with meatal skin and to limit the seepage of the irritant solution to the middle ear. In the study done by Hurst, a gauze wick saturated with hydrocortisone, clotrimazole, framycetin, and gramicidin was inserted.⁸ Abou-halawa et al proposed self-medication with clotrimazole solution on Q-tips.²¹

Moreover, otolaryngologists should be aware of the ototoxic potential of some antifungal agents.²² These medications may reach the inner ear by perfusion via the round window membrane.²³ Arguably, some of the antimycotic agents have been implicated as a cause of sensorineural hearing loss by inflicting damage to the inner hair cells of the organ of corti.²⁴ It should be emphasized that apart from the active ingredient, all commercially available antifungal otic drops contain alcohol, solvents, acids, and antiseptics. Tom et al performed a controlled animal study in which the ototoxicity of commonly used topical antifungal agents was investigated by measurement of hair cell loss.²⁴ Five readily available topical antimycotic preparations were instilled into the middle ears of test animals during a 7-day period. This study suggested that clotrimazole, miconazole, and tolnaftate are potentially safer antimycotic choices than nystatin for the treatment of otomycosis in patients with a perforated eardrum. Moreover, it was found that gentian violet has the potential for severe damage in inner ear. Ho et al observed transient sensorineural hearing loss associated with the use of cresylate otic drops.⁶ Unfortunately, a small number of antifungals and other major ingredients (solvents) have been tested for ototoxicity in experimental animals. There have not been any clinical studies on humans for sensorineural hearing loss after the use of otic antimycotic drops. Making comparisons of ototoxicity between experimental animals and humans requires caution.

Rate of Persistent Tympanic Membrane

Prognosis of otomycosis with perforated TM in general is favorable, Namely, most perforations, especially small, tend to resolve with proper medical treatment.¹⁹ Restoration of the unique milieu of deep part of external auditory meatus seems to be a prerequisite for this closure.⁸ On the other side, the possibility of a persistent TM defect is not insignificant. It is worth mentioning that some authors reported quite high rate of persistent TM perforation.¹⁶

These cases are managed with tympanoplasty with good results.^6,8,16 Namely, in all patients, complete closure of the defect was achieved. The only residual hearing loss was in a case with almost total disintegration of the tympanic membrane.⁸

The duration of follow-up before performing tympanoplasty differs between studies. Namely, Hurst et al performed tympanoplasty in cases that failed to heal within a month.⁸ On the other hand Song et al followed patients for at least 3 months before proceeding with a surgical intervention.¹⁶

Conclusions

Based on the available literature, it seems that tympanic membrane perforation associated with otomycosis is not uncommon. Otolaryngologists and even primary care physicians should be aware of this clinical feature of fungal otitis externa. The main difficulty in managing this condition is the fact that the seepage of topical antifungal ear drops to the middle ear cavity may cause intense pain and severe burning sensation. Additionally, some antifungal agents may be ototoxic. Most of the perforations secondary to otomycosis tend to resolve with medical treatment, but some persist and require tympanoplasty.

Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.

References

1.	Fasunla, J, Ibekwe, T, Onakoya, P. Otomycosis in western Nigeria. Mycoses. 2008;51(1):67–70. Google Scholar | Medline
2.	Jackman, A, Ward, R, April, M, Bent, J. Topical antibiotic induced otomycosis. Int J Pediatr Otorhinolaryngol. 2005;69(6):857–860. Google Scholar | Crossref | Medline
3.	Munguia, R, Daniel, SJ. Ototopical antifungals and otomycosis: a review. Int J Pediatr Otorhinolaryngol. 2008;72(4):453–459. Google Scholar | Crossref | Medline
4.	Stern, JC, Lucente, FE. Otomycosis. Ear Nose Throat J. 1988;67(11):804–810. Google Scholar | Medline
5.	Pontes, ZB, Silva, AD, Lima Ede, O. Otomycosis: a retrospective study. Braz J Otorhinolaryngol. 2009;75(3):367–370. Google Scholar | Crossref | Medline
6.	Ho, T, Vrabec, JT, Yoo, D, Coker, NJ. Otomycosis: clinical features and treatment implications. Otolaryngol Head Neck Surg. 2006;135(5):787–791. Google Scholar | SAGE Journals
7.	Kurnatowski, P, Filipiak, A. Otomycosis: prevalence, clinical symptoms, therapeutic procedure. Mycoses. 2001;44(11-12):472–479. Google Scholar | Crossref | Medline
8.	Hurst, WB . Outcome of 22 cases of perforated tympanic membrane caused by otomycosis. J Laryngol Otol. 2001;115(11):879–880. Google Scholar | Crossref | Medline
9.	Kumar, KR . Silent perforation of tympanic membrane and otomycosis. Indian journal of otolaryngology. 1984;36(4):161–162. Google Scholar
10.	Viswanatha, B, Sumatha, D, Vijayashree, MS. Otomycosis in immunocompetent and immunocompromised patients: comparative study and literature review. Ear Nose Throat J. 2012;91(3):114–121. Google Scholar | SAGE Journals
11.	Barati, B, Okhovvat, SA, Goljanian, A, Omrani, MR. Otomycosis in central iran: a clinical and mycological study. Iran Red Crescent Med J. 2011;13(12):873–876. Google Scholar | Medline
12.	Anwar, K, Gohar, MS. Otomycosis; clinical features, predisposing factors and treatment implications. Pak J Med Sci. 2014;30(3):564–567. Google Scholar | Medline
13.	Pradhan, B, Tuladhar, NR, Amatya, RM. Prevalence of otomycosis in outpatient department of otolaryngology in Tribhuvan University Teaching Hospital, Kathmandu, Nepal. Ann Otol Rhinol Laryngol. 2003;112(4):384–387. Google Scholar | SAGE Journals
14.	Jia, X, Liang, Q, Chi, F, Cao, W. Otomycosis in Shanghai: aetiology, clinical features and therapy. Mycoses. 2012;55(5):404–409. Google Scholar | Crossref | Medline
15.	Ozcan, M, Ozcan, M, Karaarslan, A, Karaarslan, F. Otomycosis in Turkey: predisposing factors, aetiology and therapy. J Laryngol Otol. 2003;117(1):39–42. Google Scholar | Crossref | Medline
16.	Song, JE, Haberkamp, TJ, Patel, R, Redleaf, MI. Fungal otitis externa as a cause of tympanic membrane perforation: a case series. Ear Nose Throat J. 2014;93(8):332–336. Google Scholar | SAGE Journals
17.	Ozcan, M, Ozcan, KM, Karaarslan, A, Karaarslan, F. Concomitant otomycosis and dermatomycoses: a clinical and microbiological study. Eur Arch Otorhinolaryngol. 2003;260(1):24–27. Google Scholar | Medline
18.	Kiakojori, K, Bagherpour Jamnani, N, Khafri, S, Mahdavi Omran, S. Assessment of response to treatment in patients with otomycosis. Iran J Otorhinolaryngol. 2018;30(96):41–47. Google Scholar | Medline
19.	Viswanatha, B, Naseeruddin, K. Fungal infections of the ear in immunocompromised host: a review. Mediterr J Hematol Infect Dis. 2011;3(1):e2011003. Google Scholar | Crossref | Medline
20.	Rutt, AL, Sataloff, RT. Aspergillus otomycosis in an immunocompromised patient. Ear Nose Throat J. 2008;87(11):622–663. Google Scholar | SAGE Journals
21.	Abou-Halawa, AS, Khan, MA, Alrobaee, AA, Alzolibani, AA, Alshobaili, HA. Otomycosis with perforated tympanic membrane: self medication with topical antifungal solution versus medicated ear wick. Int J Health Sci (Qassim). 2012;6(1):73–77. Google Scholar | Crossref | Medline
22.	Marsh, RR, Tom, LWC. Ototoxicity of antimycotics. Otolaryngol Head Neck Surg. 1989;100(2):134–136. Google Scholar | SAGE Journals
23.	Spandow, O, Anniko, M, Moller, A. The round window as access route for agents injurious to the inner ear. Am J Otolaryngol. 1988;9(6):327–335. Google Scholar | Crossref | Medline
24.	Tom, LWC . Ototoxicity of common topical antimycotic preparations. Laryngoscope. 2000;110(4):509–515. Google Scholar | Crossref | Medline

View Abstract